The diphtheria epidemic continues active. The outbreak that began in Bolívar state in mid-2016 persists three years later and keeps taking lives. In its latest epidemiological bulletin, date Monday, March 18, the Pan American Health Organization (PAHO) confirmed ten deaths from this cause in Venezuela as of epidemiological week 8, February 24.

PAHO warns that the case fatality rate of confirmed cases has risen, from 20% in 2018 to 26% in 2019.

Venezuela's health department stopped publishing regular bulletins sometime in 2016 or thereabouts. Since then, various professional groups have tried to estimate just how many Venezuelans have been falling ill with various diseases, of which diphtheria is only one.

So I guess it's nice that the Maduro government is at least talking to PAHO. To the best of my knowledge, Venezuela never reported reliable numbers during the Zika outbreak, whether of Zika itself or Zika-related microcephaly and other neurological disorders. We will be a long time repairing the grievous lapses in South American public health caused by purely political decisions in Caracas.

January 18, 2019

Zika virus (ZIKV) infections and suspected microcephaly cases have been recently reported in Angola, but no data are available on the origins, epidemiology, and diversity of the virus.

Methods:

Serum samples from 54 suspected ZIKV cases, 76 suspected microcephaly cases, and 24 mothers of infants with suspected microcephaly were received by the Angolan Ministry of Health. Computed tomographic brain imaging and serological assays (PRNT) were conducted on one microcephalic infant. All sera were tested for ZIKV by RT-qPCR. 349 samples from HIV+ patients and 336 samples from patients suspected of chikungunya virus or dengue virus infection were also tested. Portable sequencing was used to generate Angolan ZIKV genome sequences, including from a ZIKV+ neonate with microcephaly born in Portugal to an Angolan resident. Genetic and mobility data were analysed to investigate the date of introduction and geographic origin of ZIKV in Angola.

Findings:

Four autochthonous cases were ZIKV positive via RT-qPCR, with all positive samples collected between December 2016 and June 2017. Viral genomes were generated for two of these cases, and from the neonate with microcephaly identified in Portugal. Genetic analyses and other data indicate that ZIKV was introduced to Angola from Brazil between July 2015 and June 2016. This introduction likely initiated local ZIKV circulation in Angola that continued until June 2017. The scanned microcephaly case showed brain abnormalities consistent with congenital Zika syndrome and serological evidence for maternal ZIKV infection.

Interpretation:

Our analyses confirm the autochthonous transmission of the ZIKV Asian lineage in continental Africa. Conducting ZIKV surveillance throughout Africa is critical in the light of presented evidence for autochthonous ZIKV transmission in Angola, and associated microcephaly cases.

December 12, 2018

The Zika virus has faded from the world’s headlines. But the damage the strange mosquito-borne virus inflicted on some children whose mothers were infected during pregnancy very much remains.

A new study, published Wednesday in the New England Journal of Medicine, reports that in a group of Zika babies from Brazil who are being followed to assess their progress, 14 percent had severe developmental problems.

This was higher than previous studies have suggested, said Dr. Karin Nielsen-Saines, one of the authors.

These children scored unusually low scores on testing of their cognition, motor, or language skills, or they had visual or hearing impairment.

“It was either both things or one or the other,” explained Nielsen-Saines, a professor of pediatric infectious diseases at the David Geffen School of Medicine at the University of California, Los Angeles.

Nielsen-Saines and her co-authors, a number of whom are from Brazil’s Oswaldo Cruz Foundation, wanted to chart what Zika would do over the long term to children born to mothers infected during pregnancy. So they followed a cohort of 182 children.

Of those, 131 were brought in by their parents for follow-up testing that involved at least one of the following: brain imaging, eye examinations, hearing tests, and a standardized test used to assess the development of children in the first few years of life. The test is called the Bayley Scales of Infant and Toddler Development, or Bayley-III.

The testing was done in the second year of life for these young children, between the ages of 12 to 18 months in most cases. Nielsen-Saines said the work is ongoing and the group is currently assessing later data from these children, who they plan to study until at least the age of 7.

Of the total, 94 of the children underwent both imaging and the Bayley-III assessment; 63 percent of them had scores that were in the normal range for cognition, motor, and language skills. But 14 percent had severe neurodevelopmental delays.

Six of the children had microcephaly and were so profoundly impacted that in essence the Bayley test could not be conducted, Nielsen-Saines said. Another roughly 15 percent had moderate developmental delays, she said.

November 19, 2018

Zika virus is back on the global radar. With confirmed cases in the most populated countries in the world, China and India, concerns raised over Nigeria’s Zika virus preparedness since the most recent update was issued 2 years ago. Furthermore, Zika virus disease is not on NCDC’s directory of diseases that affect Nigerians although it had previously affirmed that Nigeria is at risk of the Zika virus disease.

In its ZIka virus risk assessment for Nigeria, the NCDC stated: “NCDC plans to initiate surveillance to understand and monitor the epidemiology of Zika virus in Nigeria for the appropriate interventions.” But there has not been any official publicly available publication on the disease since.

Zika is back

Late October 2018, Chinese Customs Authorities reported they had detected the first case of imported Zika virus in 2018 in a man who had recently traveled to the Maldives. The tourist showed symptoms including a fever and rash when arriving at Baiyun International Airport on Oct. 19 in Guangzhou, south China’s Guangdong Province, according to the General Administration of Customs (GAC).

Alarmed customs staff arranged a medical examination and found him Zika-positive two days later, the GAC said in an online announcement without identifying the patient, who was later quarantined at a local hospital.

In a similar way, few days ago, the Zika virus disease reemerged in India with over 20 cases confirmed already thus raising concerns about Nigeria’s preparedness to prevent and contain an outbreak.

Zika is different

The well documented Zika virus experience in Brazil and across Latin America can be seen as a good overview of a classical outbreak of Zika virus disease.

Between 2014 and 2016, a virus spread quickly through the Brazil and other Latin American countries, called Zika virus. Since it usually has very mild, or no symptoms, it took about a year for Brazil to confirm the first case of the disease. By then the outbreak was already widespread.

It was not labelled a public health emergency until February 2016 when microcephaly – which is when infants are born with small heads with permanent brain deficits- and other neurological sequelae were noted in babies born about that time.

The factors associated with the rapid spread of Zika virus in Brazil such as a population that may be non-immune, a high population density, a conducive climate and inadequate control of Aedes mosquitoes could also describe why many African countries are Zika virus-prone zone today. Most of West Africa is at risk of Zika virus including Nigeria, Ghana and Guinea Bissau.

An invisible epidemic

In April – June 2016, just as the outbreak in Brazil was spreading, cases of Zika virus infection and microcephaly in infants were reported in Guinea Bissau.

In a 2017 Lancet article on the extent of Zika virus in Africa, about 6 out of 100 blood samples tested from people with fever in Senegal and Nigeria tested positive for the Zika virus infection. Zika virus was called the ‘invisible epidemic’ in the Lancet article.

In this study, we described a high prevalence of confirmed CBAs in Salvador, as high as 2.2% of the live births in December 2015. The prevalence of image-confirmed CBA estimated for the study period adjusted for one year was 52 times higher than the estimated baseline prevalence of microcephaly in the north-east region (average of 5 cases per 100,000 live births per year, between 2000 and 2014). Unfortunately, we did not have information on serological or virological ZIKV testing, which would allow ascertaining the aetiology of such an outbreak.

However, the peak of births of babies with microcephaly occurred 30–33 weeks after the peak of ZIKV epidemic in Salvador, and this is consistent with the growing body of evidence suggesting that the first trimester of pregnancy is the period when ZIKV infections pose the highest risk of adverse fetal outcome. Taken together, it is reasonable to assume that most of the imaging-confirmed cases in this study were due to congenital ZIKV infection.

As we only considered cases with specific neuroimaging findings as confirmed cases, we certainly underestimated cases of congenital ZIKV infection. Several suspected cases had not been investigated by the time we analysed the data and the imaging modality most commonly used was prenatal or postnatal intracranial ultrasound, which is not an optimal modality to detect abnormalities of the corpus callosum and cerebral cortex.

In addition, suspected microcephaly cases were reported based on birth head circumference, which could be well within normal limits in some cases of congenital ZIKV infection. Although reporting of spontaneous abortions, stillbirths and fetuses presenting alterations in the central nervous system was also encouraged, allowing us to confirm a few cases with normal or large head circumference at birth, we could not evaluate whether there was an increase in abortions and stillbirths in Salvador during the study period.

On the other hand, some cases counted as confirmed could be due to other causes such as congenital cytomegalovirus infection or genetic disorders, but the number of these cases is expected to be small, considering the baseline rate of microcephaly before the epidemic. In addition, in north-east Brazil (a region in which Salvador was one of the epicenters for the ZIKV outbreak), only 1.3% of confirmed cases of infection-related microcephaly during the 2015–16 period had laboratory evidence of syphilis, toxoplasmosis, cytomegalovirus, or herpes simplex.

A similar increase in microcephaly cases was reported in other locations where ZIKV epidemics have occurred, such as Colombia, where the prevalence of microcephaly also increased around 6 months after the peak of ZIKV transmission in July 2016. However, the microcephaly prevalence reported in Colombia peaked at 17.7 cases per 10,000 live births, much lower than observed in Salvador. Potential reasons for this difference may include, variable intensity levels of ZIKV transmission, differences in circulating ZIKV strains and different case definitions and surveillance criteria. Further, co-circulation of other arboviruses (dengue and chikungunya, for example), differences in mosquito control measures, and prior exposure to yellow fever vaccination could be contributing factors.

Additionally, Brazil was the first country in the Americas to experience a large outbreak of ZIKV and to detect an increase in microcephaly cases, and this allowed other countries as Colombia to issue recommendations for delaying pregnancies, which might have resulted in decreased risk of congenital abnormalities associated with ZIKV infection during pregnancy.

October 17, 2018

Emiliano Cula starts to cry as his tiny fingers, curled into a tight fist, are stretched by a physical therapist to stimulate motor control.

Born in a poor neighborhood of Angola's capital Luanda, the 10-month old boy has microcephaly, a birth defect marked by a small head and serious developmental problems. He still can't sit upright and has difficulty seeing and hearing.

"They don't know what caused it," Cula's mother Marie Boa says, sheltering under a blue umbrella from the summer rains. "The doctor said it might have been caused by a mosquito, but I don't know if that's true." The 18-year-old does not know whether her first child will ever walk or talk.

Cula is one of at least 72 babies born with microcephaly in Angola between February 2017 and May 2018, suspected victims of an emerging Zika outbreak. The cases have gone largely unreported, but an internal World Health Organization report reviewed by Reuters concluded in April that two cases of a potentially dangerous strain of Zika confirmed in early 2017, along with the microcephaly cases identified since then, provided "strong evidences" of a Zika-linked microcephaly cluster in Angola.

A lack of data and diagnostic testing along with a woefully inadequate Angolan health system has made tracking the outbreak difficult. But new findings from a research team in Portugal suggest it is the first on the African mainland involving the Asian strain of the disease.

It was the Asian strain that caused at least 3,762 cases of Zika-related birth defects, including microcephaly, in Brazil since 2015, as well as serious outbreaks in other Latin American countries. Doctors and researchers now fear it could spread from Angola to other countries on the African continent.

In an emailed response to questions, Angola's ministry of health said it had reports of 41 cases of Zika and 56 cases of microcephaly since January 2017, when it began gathering data. It was not immediately clear why the figures differed from the internal WHO report.

A lack of testing capacity means many cases of microcephaly go undetected, the ministry added, noting also that microcephaly has many causes.

"Probably not all the cases of microcephaly can be attributed to Zika," the ministry said, listing a series of other potential causes such as syphilis and rubella.

The Angolan outbreak comes at a time when world attention has moved on from Zika, and most of the more than $1 billion in U.S. funding allocated to fight the disease has been spent.

"We can't let our attention down on this," said Eve Lackritz, a physician who leads WHO's Zika task force. "We have to stay vigilant and have a sustained response."

October 09, 2018

NEW DELHI, Oct 9 (Reuters) - India has sent experts to try to contain an outbreak of the zika virus in the popular tourist destination of Jaipur, capital of the northern state of Rajasthan, with a close watch on pregnant women.

Twenty-two people in the city have tested positive, the health ministry said. There is no vaccine to the virus which can cause severe birth defects in unborn children.

Pregnant women in the area are being monitored by the National Health Mission, a body set up by the government to improve healthcare across the country.

"The situation continues to be monitored regularly," the ministry said in a statement late on Monday.

The Toronto-based International Association for Medical Assistance to Travellers said it was advising pregnant travellers to postpone trips to the area, part of India's tourist "golden triangle" of Delhi, Jaipur and Agra, home to the Taj Mahal.

First discovered in 1947, the Zika virus reached epidemic proportions in Brazil in 2015, when thousands of babies were born with microcephaly, a brain defect affecting speech and motor function.

It is the third such outbreak in India, with the first in the western city of Ahmedabad in January 2017 and the second in the southern state of Tamil Nadu in July 2017. Both outbreaks were "successfully contained", the government said.

The latest cases - in the middle of the country's festival season where many Indians travel, increasing the risk of transmission - come amid a spike in other mosquito-borne diseases, that kill thousands across India each year, according to the World Health Organisation.

BACKGROUND: Zika virus has been responsible for recent outbreaks in the western hemisphere with known neurological complications such as microcephaly. This complication has not been previously documented in continental Africa.

METHODS: Neurological evaluation of the newborn was performed after birth, at one and two months of age. The mother and the newborn sera samples were tested by immunofluorescent assay (IFA; immunoglobulin G [IgG] and IgM) for Zika virus and the presence of Zika virus ribonucleic acid (RNA) was checked by qualitative real-time reverse transcription polymerase chain reaction (RT-PCR) in placenta, blood and urine samples.

RESULTS: We report on a newborn, born in Portugal, with microcephaly with confirmed congenital Zika virus infection (Asian lineage) imported from Angola with typical clinical and imaging findings.

CONCLUSIONS: To our knowledge this is the first report that shows the circulation of the Asian lineage in Angola and the first report of a congenital Zika syndrome in continental Africa.

July 20, 2018

Brazil’s “invisible children”, the thousands of babies born with neurodevelopmental disorders, have been brought out of the shadows by the Zika virus epidemic and their families may get help for the first time.

Almost 4,000 babies were born in Brazil with microcephaly as a result of Zika virus infection – a brain malformation that left them with small and misshapen heads and poor developmental prospects.

But nobody knows how many babies have been born in Brazil with other developmental disorders. They are invisible all over the world, where it is estimated there are 250 million children with developmental delay or disability. The numbers are thought to be probably twice as high in the developing world as they are in the more prosperous countries of North America and Europe.

“Zika affected probably a relatively small amount of children – a few thousand. The epidemic came and went and hasn’t come back,” said David Edwards, a professor of paediatrics and neonatal medicine at King’s College London.

It was a tragedy for each of them and their families, he said, but the numbers “pale into insignificance compared with the large number of children who are affected by neurodevelopmental disorders.”

The two most common causes of death and disability in newborn babies are birth asphyxia and prematurity. Well-equipped modern hospitals in the western world can prevent much of the death and damage from these causes. But women in poor countries may have far to go to reach a maternity unit and can have very long labours. A colleague of Edwards working in Uganda told him: “We think 12 hours is a long labour. They think 12 days is a long labour.”

Many women in developing countries are malnourished, which increases the risk to mother and baby. Genetic factors causing such disorders as Down’s syndrome and fragile X play a part in all countries.

“Brazil has invested heavily in child health [areas] such as immunisation, where we are very strong,” said Maria Elisabeth Lopes Moreira, professor of neonatal growth and nutrition at the Oswaldo Cruz Foundation in Brazil. “I think that there is a lack of data on the development of children and this is part of the problem. We don’t know exactly the numbers. They need support in the very early days of life. We really need some investment in these children.”

Some of them, from the poorest families, have parents who work and older siblings are charged with looking after them. “We have children taking care of children,” she said. “It is too difficult for them.”

She and Edwards were part of an expert group brought together to discuss childhood neurodevelopmental disorders in Brazil by the UK’s Academy of Medical Sciences and the Academia Brasileira de Ciências at a workshop in Rio de Janeiro. The group’s report calls for more to be done for the invisible children not only in Brazil but around the world.

Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system.

We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.